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AUGUST 5, 2013

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Technology n Upper Limb Prosthetics n Simulation & Student Learning n Apps for OT

9OT PRACTICE • AUGUST 5, 2013

on Ius was born without a right hand and has been using a prosthesis since he was 2 years old. Until

recently, he had never worked with an occupational therapist.

“I had never had anybody work with me to find good ways to use the prosthesis. I had invented my own ways to do what I needed to do, and in my own mind felt like I was pretty much capable of doing anything I wanted to do,” he says.

And capable he was. He figured out how to use his hook to operate the shift key on his computer when typing so he could make a career as a software engineer. He also figured out how the hook could help balance sheet music

in a binder on his right arm and pin the binder against his chest so that he could hold it during rehearsals and performances with his local choir.

But the solutions were not without glitches. Sure, his hook could hold down the shift key, but that still meant he was essentially typing with one hand. And during long choir rehearsals, the binder position forced him to look down instead of out at his conductor.

Also, his shoulder would often tire and cause him to lose the balance of the binder and drop his sheet music onto the floor.

With these issues in mind, Ius decided to research new technology and came across the i-limb ultra- revolution hand, made by Touch Bionics. Among many innovative features, it allows users to manipu-late the fingers individually and take

Occupational therapists help clients make the most of their prosthetic devices so they can get back to the tasks, skills, and activities that matter.

Stronger Grip

Occupational Therapy’s Vital Role in the Upper-Limb Prosthetics Industry

ANDREW WAITE

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advantage of 24 different grip patterns that can be accessed by using a tablet or smartphone. Up to five different grip patterns can be programmed to be accessed by the user through patterns of myoelectric input. The ios app provides the Quick Grasp feature, which allows the user to select any of the grip patterns directly. At the time of this writing, occupational therapists specializing in prosthetics as well as other industry experts in the field of prosthetic rehab who were interviewed for this article were calling this the lat-est and greatest advancement in upper limb technology.

Before Ius knew it, Advanced Arm Dynamics, a national company devoted to upper limb prosthetic rehabilitation that employs full-time occupational therapists at each of its clinics, con-tacted him after he requested informa-tion on their Web site. After the phone conversation, he was convinced that Advanced Arm Dynamics was a good fit and the best choice for his prosthetic care, and he committed to traveling to Portland, Oregon, to be fitted for his i-limb ultra-hand. There, he was intro-duced to Kerstin Baun, MPH, OTR/L, who helped him learn how to use his new limb (with Ius’ insurance company covering the costs). It was the first time he had ever had professional help in this capacity.

Just a few weeks after being fitted with his new prosthetic device, Ius had

a choir performance. In Portland, Baun had helped Ius find a grip pattern that allowed him to stabilize the binder of sheet music in his i-limb device so he could hold it out away from his body. The grip pattern meant Ius could easily bounce his eyes from the conductor to the sheet music as well as turn the page with his other hand.

“It felt different,” Ius says of the first performance with the i-limb. “For once, I didn’t have to keep bending my head down all the time. I could hold the music up and I could watch the director 90% of the time just by glancing with my eyes rather than having to move my whole head up and down. And I never was at a risk of dropping the music. It felt really secure, and it may sound funny, but I felt normal. I looked like and was behaving like everybody else.”

Ius’ story is not meant to give his work with occupational therapy all the credit for his success. The technology itself, the prosthetist who built and adjusted a well-fitting prosthetic, a sup-portive family, and many other factors contributed to Ius’ improved function-ing. But it does show occupational ther-apy’s potential to make a good impact on the upper limb prosthetics industry due to the focus on how individuals function with the technology. As more resources become available, those in the industry say occupational thera-pists are vital to the future of upper limb prosthetics. Occupational ther-

apists are the professionals who help clients learn to actually use the pros-thetics and to successfully incorporate the most appropriate devices into their lives so they can get back to performing necessary and desired tasks, skills, and activities.

HOW OCCUPATIONAL THERAPy HELPSIf the client is unable to properly use the prosthetic device, it doesn’t really matter how far technology has advanced.

“We are on the front lines of training someone to use these arms and hands to prepare the patient to really return to functional independence,” says Diane Atkins, OTR/L, FISPO, who works as an independent consultant in the upper limb prosthetics industry.

Occupational therapists’ work with a client begins even before the device enters into the equation. If clients are new amputees, occupational therapists will perform scar tissue massages and wound management on the amputated site.

For Jason Koger (www.jasonkoger.com), the first double hand amputee to be fitted with the i-limb hand, wound management was where occupational therapy made a big impact. Scars from his surgery were limiting his elbow movement.

“My doctor said, ‘You have to go to therapy because they have to keep this PH

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Collaboration between the prosthetist,

therapist, and patient begins with the initial

evaluation and continues throughout the fitting and training process.

11OT PRACTICE • AUGUST 5, 2013

scar down.’ So I was going to therapy two times a day. My therapist was doing scar management, ultrasound, every-thing. And now I have no scar, and I have 100% range of motion,” he says.

Also, before the device is available, occupational therapists evaluate a cli-ent’s activities of daily living (ADLs) as performed without the prosthesis.

“Even when [clients] do get a pros-thesis, they are not going to wear it 100% of the time, and it’s important for the patient to have options for indepen-dence,” Baun says.

Then begins the preparatory pros-thetic work. Even before Ius was fitted with the i-limb ultra, as part of Baun’s initial evaluation, she and a prosthetist had to help determine what sites on Ius’ forearm could be used to control his new device.

In training that sounds a bit like the Nintendo Wii, an image of a hand was

projected onto a screen while sen-sors were attached to Ius’ limb. As he activated the sensor with a movement such as flexing his wrist, the hand on the screen moved accordingly. Baun was there to help Ius think through the movements and understand the cor-relation between, say, flexing his wrist and opening or closing the prosthesis. Such preparatory work helped Ius become accustomed to how he would operate his new mechanical limb.

Once the client receives his or her prosthesis, “then we do a lot of work with it,” Baun says. “Initially, it’s a lot of rote practice. Open, close. If they have wrist rotation, it’s also teaching them how to use that component, including wrist flexion/extension, or elbow and shoulder components for those with higher level amputations.”

Quickly, rote practice translates into skills for practical prosthesis use.

During Ius’ training with his i-limb, he remembers Baun asking a lot of questions.

“How are you going to do this? Simple things just like moving blocks. Let’s see if we can open this bottle. Can you fold that? How would you eat?” Ius remembers of Baun’s training. “We actually made strawberry shortcake for lunch. I had to cut the strawberries and whip the cream.”

Baun says the activity was to teach problem-solving skills. Together, they chose these tasks because Ius had expressed interest in wanting to be able to help his wife in the kitchen.

“I was looking at how he would incor-porate the use of the prosthesis into that activity. He found it didn’t work for hold-ing onto the blender, but it worked really well for holding onto the bowl. What he figured out is how to hold onto the edge of the bowl as an assist, and then he was holding onto a lot of different sizes and shapes of containers. [It’s a matter of] figuring out what part of the activity he is going to use his prosthesis for versus what is he going to use his sound hand for. It’s giving clients the opportunity to problem solve. And when they need prompting, that’s when I step in and help them get over hurdles,” Baun says.

During these tasks, Baun also teaches her clients how to avoid com-pensatory movements.

“That’s important. It’s something that I draw their attention to and we look in the mirror and I get them to check their posture. Is the shoulder positioned awkwardly or is the client having to rotate or bend his trunk? And if so, can he figure out how to posi-tion the terminal device in a way that allows the shoulder to be positioned in a healthier way?” she explains. “Clients are just not familiar with how to use it.

Jason Koger uses two different types of prosthetic devices, body-powered prosthetic arms with hooks for hunting and outdoor activities, and i-limbs for other activities.

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12 AUGUST 5, 2013 • WWW.AOTA.ORG

So it is that initial teaching of the basic open and close and how to preposi-tion the device so that they limit the amount of compensatory movement that sets them up for success.”

In addition to ADLs, Baun helps her clients learn the skills they will need to use their prosthesis in other aspects of their daily occupations.

For Ius, that meant using the com-puter. Baun helped him shuffle through the i-limb’s various grip patterns to find and set one that he could use regularly for typing. There are up to five differ-ent patterns available at any time that the patient can access through myo-electric switching. There is the stan-dard all open/close, and then four other features or grip patterns that are cho-sen from the 24 available patterns and assigned to one of the four myoelectric triggers or patterns of contraction to switch grip modes. Two of the patterns are custom programmable for individu-alized needs such as Ius’.

“I had my laptop computer there, so we went ahead and figured out what grip pattern we were going to use,” Ius says. “I tried several until I found one that actually worked. If I kept the other three fingers open, they tended to bounce on the laptop screen. I have one where they curl underneath and just the index is sticking out and the thumb is off to the side, and it really works great,” he says. “So we experimented a few times. And she did things like ask, ‘Are you tensing your shoulders? Are they relaxed? Is the keyboard too high? Too low?’ Things like that, just to make sure that I was comfortable and that everything was working well.”

Ideally, part of the process involves the client and occupational therapist working directly with the prosthetist, who can adjust and customize the device as needed. Ius and Baun spent a good amount of time with MacJu-lian Lang, CPO, FAAOP. Collaboration

between the prosthetist, therapist, and patient begins with the initial evalu-ation and continues throughout the fitting and training process.

“One of the things that we did was set him up with the initial controls for how he would select the different grip patterns,” Lang says. “He was able to elicit those initially, but as he got into functional tasks with Kerstin [Baun], the control of the grip patterns wasn’t nearly as consistent as we had expected or wanted. So they brought that to my attention. We went back into the pro-gramming room, pulled up his signal, and then went over the criteria for how each one would get selected. Pulling up his signal indicates that we started the software that allowed us to see his myo-electric signals and analyze what was happening. We were able to compare his signals to the switching criteria and coach him to modify his contractions. That certainly improved his ability to select grip patterns very quickly. And then it’s just about working with Kerstin [Baun] to determine which grip patterns work the best with specific tasks.”

Because occupational therapists ask about clients’ hobbies, skills, and inter-ests, they are able to help clients learn to do those same things with prosthet-ics. In Ius’ case, Baun went with him to the mall to find a camera similar to his own but didn’t have on hand in Portland, so he could learn how to use the i-limb to take photos.

Major Erik Johnson, MS, OTR/L, who works at Walter Reed National Military Medical Center in Bethesda, Maryland, often works with prosthetists to build special attachments, like a kayak paddle, that fit onto a prosthetic device to help his clients continue with their adventures.1

“With 100 different clients come 100 different things that they want to do,” Johnson says. “The point where we sit back with the patient and say,

As technology advances...occupational therapy’s role is

broadening to help the client simply learn how to use the

technology, say occupational therapists in the industry.

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‘Okay, tell me about your hobbies. What do you want to be able to do?’ They will reciprocate with, ‘Well, I used to kayak and I used to do winter sports.’ But they will say they can’t do that any more. Well, as an OT, a lot of the job is to be able to say ‘Actually, I can help with these activities. They may look dif-ferent or be accomplished differently, but we can still do those.’”

These are just some of the ways occupational therapists help their clients learn to use a prosthetic device. But just as every client is unique, the care provided is just as individualized.

INDUSTRy UPDATEOccupational therapists who work in prosthetics say one of the best ways to learn about the industry is to talk to the prosthetists, the people who make and adjust the devices. Lang, who has worked in the prosthetics industry for about 25 years, notes that there are two basic kinds of prosthetic devices: Biomechanical and myoelectric. Bio-mechanical devices are operated with body movements. They are typically hooked to cables that can be manipu-lated with shoulder or torso movement to open and close the hand or hook.

“Traditional cable-driven prosthet-ics aren’t significantly different than they were 30 years ago,” says Lang. “The socket is the interface between the person and the prosthesis, and the techniques for creating sockets have

improved. The materials that are used have evolved and are more lightweight. But from a ground level—how the pros-thesis works—it hasn’t changed all that much. When it comes to myoelectrics, though, a lot has changed.”

Myoelectric prosthetic devices are battery-powered devices that are operated with a patient’s myoelectric signals, the body’s electrical impulses that lead to muscle contractions and therefore voluntarily movement.

“In the past 5, 10, and 15 years, the technology has grown in leaps and bounds,” Lang says.

The Defense Advanced Research Projects Agency has put a lot of funds into research and development primar-ily because of wounded soldiers return-ing home from the wars in Afghanistan and Iraq, Lang says.2

Just as cell phone batteries are shrinking in size and allowing devices to become smaller and smaller, batter-ies for prosthetic devices have become smaller and more flexible.

And the “hands” themselves are improving as well. Now, at least three hands on the market (bebionic 3, Michelangelo, and the i-limb) have fingers that can be individually involved in the generation of grasp or pinch. For more information on these products, check out http://armdynamics.com/pages/new-technology.

Going forward, Lang expects devices with improved and increased electric

input, including pattern recognition. Such advances would mean users can essen-tially do less to get more from their hand.

“The percentage of people that are being successfully fit, meaning they are using the prosthesis successfully, is on the rise. Anecdotally, there is a big increase in the number of myoelec-tric users because these devices have been improved from a technological standpoint. Some of the reasons people rejected wearing a prosthesis in the past—being too heavy or moving too slowly—are less of an issue now,” Lang says.

He also expects future hands to have improved input reception, allow-ing for the devices to more accurately know what users are trying to make them do.

“[That’s] going away from the tra-ditional two-site myoelectric system to something that has four inputs. In a standard two-site system, we use two electrodes on separate muscle groups to achieve all of the functions of the prosthesis. This could be as many six different functions, including hand open and close, wrist rotation, and elbow flexion/extension. Providing more inputs gives the user more direct control of the motions, which can lead to decreased cognitive effort and improved speed and accuracy of control. So [there will be] either more electrodes or pattern rec-ognition or direct neural integration. We are going to see things like that in our PH

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Occupational Therapist Kerstin Baun works with a client on kitchen skills.

“ We are on the front lines

of training someone to

use these arms and hands

to prepare the patient to

really return to functional

independence.”

14 AUGUST 5, 2013 • WWW.AOTA.ORG

market in the next 5 years,” Lang says. “It’s going to happen. It’s an exciting time to be in upper limb prosthetics.”

WHAT IT MEANS FOR OTAs technology advances, occupa-tional therapy’s role becomes even more important. With older prosthetic devices, the practitioner’s job focused on how to adapt activities so they could be accomplished with a hook or tripod hand. Now, occupational therapy’s role is broadening to help the client simply learn how to use the technology, say occupational therapists in the industry.

“Now you have options, so let’s explore which is going to be the best one,” Baun says of the shifting role. “That’s the new challenge, but it’s a really fun one.”

It’s a role change that allows occupa-tional therapists more chances to help clients achieve more “normal” per-formance of daily activities with their upper extremity.

“Some clients just need that gross motor grasp; others want to be able to individually manipulate small objects, Johnson says. “Or, if they have a child, they want to be able to have a hand that they can wrap around the child. These advancements give you an opportunity to engage in patient care. And I think each one that is made [moves us] one step closer to being able to find options [for clients] that are as close to their previous lives as possible.”

Of course, the other challenge for occupational therapists is staying cur-rent with the technology advances.

“OTs in general who work with upper limb clients have to be more technologically savvy than they were in the past,” Lang says. “The pieces and parts that we use now have a much higher level of technological sophisti-cation. Understanding that and being familiar with the spectrum of prosthetic components allows the therapists to really tailor their treatment plans to the person, so that not everyone gets the same thing.”

Fortunately, manufacturers are seeking occupational therapy input when developing new devices.

“Manufacturers talk to us about treatment protocols that we might recommend for a certain type of hand,

or they might ask us to work with a patient with this hand and give feed-back. That’s how we partner with them to bring better products to market,” says Tiffany Ryan, MOT, OTR, national director of Therapeutic Services at Advanced Arm Dynamics. “Occupa-tional therapists who want to work in prosthetic rehabilitation may find this specialization is not focused on very much in most OT programs. The best sources for learning are industry- specific organizations and publications, and specialists working in the field of prosthetic rehabilitation. Manu-facturers seek our input because no one wants the patient to have to use an awkward body position or contort his or her posture in order to access the new grip pattern, for example. You want it to seem really natural. So we are able to give them some good feedback, and give them objective data from our outcomes measures, and they are able to use that to modify the technology.”

Although technological advances can sometimes seem to complicate life, advances in prosthetics can actually make adjusting to the devices easier than in the past. The more advanced devices become, especially as they are made with occupational therapy input focused on real-world functioning, the closer they come to looking and behav-

ing like sound limbs. That means that, despite how advanced the technology becomes, the core goal of occupational therapy—to improve function—remains the same. Sure, occupational therapists who regularly work with patients with amputations should seek advanced training, but ultimately, occupational therapy’s role comes back to things like body mechanics, task analysis, range of motion, and, most importantly, function.

“As OTs, we have new challenges all the time,” says Julie Klarich, OTR/CHT, who worked with Aron Ralston after he amputated his own arm to free himself from a boulder, and whose story became the basis of the film 127 Hours.3 “I often get these panicked calls from OTs saying, ‘Oh, my gosh I, don’t know anything about prosthetics.’ And I always tell them: ‘You have these skills. You have been trained in all these things. You are an OT.’” n

References1. Strzelecki, M. (2010). Molly asks: Cpt. Eric

Johnson. OT Practice, 15(9), 32.2. Yamkovenko, S. (2011). The new wounds of war:

Polytrauma care and occupational therapy. OT Practice, 16(21), 13–18.

3. Waite, A. (2013). Keynote speaker—Aron Ralston. OT Practice, 18(7), 24.

This article: http://dx.doi.org/10.7138/otp.2013.1814f1

Andrew Waite is the associate editor of OT Practice.

He can be reached at awaite@aota.org.

F o R M o R e i N F o R M A T i o NAOTA Fact SheetThe Occupational Therapy Role in Rehabilitation for the Person With an Upper-Limb Amputation www.aota.org

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